Saturday, October 29, 2005

Death Pays a Call to Keith Carlson's blog

Death Pays a Call is a beautiful post written by Keith Carlson on his professional experience midwifing a patient (and his family) through his dying. Check it out!

Thursday, October 27, 2005

My Grandmother's Sense of Humor

This morning, I've been going through some of my grandmother's old papers that were passed on to me at the time of her death: postcards from trips, an academic paper on Christian Science (her religion), passports, lists of presents she was mailing to family, etc. Amongst this pile, a small scrap of peach paper fell out, with a handwritten note from my grandmother:

When I die, I want to go peacefully like my grandfather did.
In his sleep.
Not screaming, like the passengers in his car.

My grandmother always had an interesting sense of humor.

Sunday, October 23, 2005

Euthanasia In New Orleans During Hurricane Katrina

Jeremy's blog recently referred to an article on Euthanasia in New Orleans during Hurricane Katrina. Please check it out and share with me what you think.

I have to say, reading this article, I was shocked. I am in full support of physician-assisted suicide, but am not sure that I could practice euthanasia, even if it were legal. But then again, I am not sure what I would do if I were in the shoes that these doctors and nurses were during Katrina. I'm sure that these doctors and nurses did what they felt in their hearts was the most humane and caring act under the circumstances. And all we can do is our best. They obviously could not get informed consents signed for an act that is illegal, but I think that is what worries me the most - wanting assurance that these patients were fully informed and consenting - not that they would have consented to drowning in the hurricane, if they'd had a choice in that matter.

What are your thoughts?

Monday, October 17, 2005

Your Truth: Confusion and Code Status - Part 2

I will admit, that while all identifying information has been changed, the scenario for Confusion & Code Status is based on a true situation with one of my patients.

That said, it was very interesting to read your comments with what information I provided and what additional information I have that I did not share.

To share the remainder of the story:

Mr. Garcia's mind cleared on and off the next day, so I was able to follow up and clarify his wishes. I did not think to inquire as to if he is truly on a sports team or a coach, though that would have been interesting.

As for Catherine's concern, part of the problem was that Mr. Garcia had not written an Advanced Directive stating his wishes, so there was no Advanced Directive for us to be disrespecting. In order for a DNR/DNI to be continuous through multiple hospitalizations, one must fill out an "community" DNR/DNI, which many states offer. A DNR/DNI written by one doctor during one hospitalization is only effective for that one hospitalization.

This is probably not a bad policy, as upon his mind clearing, Mr. Garcia decided that he wanted to be a full-code. I encouraged him to write an Advanced Directive so that we would know what to do should he become acutely confused again, because like most of you, the doctors were leaning towards DNR/DNI and apparently that was not in tune with where Mr. Garcia's thoughts were.

The fact that people change their minds about their goals of care is a continuous point of debate with code statuses as well as with advanced directives. What if you write out what you think you'd want knowing what you know today, but then when you're later in need of making those critical decisions, you change your mind? It's not only important to write down what your wishes are for today, but to also keep open communication with all of your loved ones as to what your goals are. For example, "If I can't do A or B, then I don't think life would be worth living; THEREFORE if I was diagnosed as being in a persistent vegetative state, then I would NOT want to be kept on a respirator." The first part of that sentence is almost more important than the last.

I never found out why Mr Garcia's family wasn't present at the bedside those first 48 hours, but they became a strong presence after. Before that, the daughter was called, as Carrie had suggested, but she was not in a mental state to be of much assistance and only answered the most basic questions. Mr. Garcia's confusion may have been too distressing for his family to witness. Even as a professional, watching Mr. Garcia come in and out of awareness was distressing and brought me near tears at times.

Perhaps Mr. Garcia decided to be a full-code to buy himself time to help his daughter accept the fact that he is dying. And that is a respectable decision. And regardless what we would want or think he should do, it's a decision only Mr. Garcia can make. Fortunately, Mr. Garcia did not code during this hospitalization.

This job is not easy. Ethical dilemmas almost never have a clearly right answer. And yes, sometimes I struggle with finding compassion towards family members. Sometimes I struggle with finding compassion towards my patients. And often, as in the case of my absence at my grandmother's death, I struggle with finding compassion for myself on this journey. But every day I pray that compassion wins.

Sunday, October 09, 2005

Your Truth: Confusion and Code Status

Before I provide you with my next scenario for your ethical debate, I want to provide a bit of a disclaimer. The scenarios I have been providing are not entirely like those that might come up in hospital ethics committees.

For ethics committees who follow Thomasma's ethical workup, the questions asked during an ethical dilemma are:

1. What are the facts of the case?
2. What are the values at risk in the case?
3. What are the main conflicts between values, professional norms, and ethical axioms, rules, and principles?
4. What are the possible courses of action, and which values do the possible courses protect or infringe?
5. Having addressed all prior questions, which course of action do we think is most ethical?

The first question, what are the facts of the case, can sometimes be the hardest. The facts are not always as clear as I've been presenting them to you in these scenarios.

In this next case, I will not unravel all of the facts. The facts themselves will be harder to interpret. Do you see how these differing facts might affect your decision?

Mr. Garcia is a 39 year-old male admitted to the hospital with uncontrolled pain from metastatic colon cancer. He is very confused; he doesn't know the date nor where he is nor the time of day. He asks you repeatedly if he is still going to be able to "play in the game." He later states, "But I am not one of the players; I'm a coach." He appears in excellent health from outward appearances despite his highly advanced cancer. His skin coloring looks healthy. His vital signs are stable and he has excellent urine output, all signs suggesting his body is holding up in spite of his progressing disease.

Mr. Garcia lives with his 18 year-old daughter whom brought him to the hospital; however, she has not been back to the hospital in the two days since his admission. He tells you repeatedly that he wants to go home to talk to her.

During Mr. Garcia's previous admission, he stated that he wished to be a DNR/DNI (do not resuscitate, do not intubate). However, due to his altered mental status, the doctors have not determined a code status yet, hoping his mind will clear before the issue of code status becomes pressing. This means that for now, Mr. Garcia is a full code (meaning all efforts will be made to keep him alive or bring him back to life if he stops breathing or his heart stops beating).

What are some potential ethical issues that might present in this case?

Although I've tried to minimize interpretting data to illustrate the difficulty in determining facts, I will provide a little more information for those of you with less of a medical background. The type of confusion that Mr. Garcia is presenting may possibly be (but may not be) attributed to what is referred to as terminal delirium (confusion that occurs in more than 25% of patients with advanced cancer in the last month of their life). However, this confusion could also have been induced by the opioids that have been used to manage Mr. Garcia's pain. Terminal delirium is not likely to respond to pharmacological interventions, whereas opioid-induced delirium may.

Okay, I'll stop there. What are your thoughts?

Saturday, October 08, 2005

Film Review: Corpse Bride

Last night, S and I went out for a date night and saw Tim Burton's Corpse Bride. We do not regularly view films with a PG rating; anyone have trouble guessing why I'd talk S into seeing this flick? ;-)

In this film, the main character, Victor, accidentally proposes to a dead woman while practicing his wedding lines for his fiance Victoria. The "corpse bride" whom he has proposed to gets lost in her fantasy of how this young man will save her and doesn't register nor understand his resistance until the end of the film.

My kindergarten teacher once told my parents that she was concerned that I was not able to differentiate between fantasy and reality. As an adult woman who is still prone to believing my fancies, I could relate to this sad "corpse bride."

I loved the imagery in the final scene. As the "corpse bride" finally makes peace with her untimely death, her soul is freed and dissintegrates into a cloud of butterflies that fly towards the moon. This was a beautiful metaphor for a mind being freed of fantasy and a soul being freed from its body.

After the film, S and I wondered what Tim Burton must be like.

Mia: I bet I'd like him. We certainly share a common interest in death. I wouldn't mind sitting down for a cup of coffee and picking his brain for a bit.

S: He's probably anti-social. And besides, he's twisted. But then again, [laughing] sometimes I think you are, too.

If you've seen this film, what do you think? Twisted or just unusually thought-provoking entertainment?

Sunday, October 02, 2005


This was the post-script on an email I received today from a classmate, Deb. I really liked it and couldn't agree more, so I thought I'd share it here:

Life should not be a journey to the grave with the intention of arriving safely in an attractive and well preserved body, but rather to skid in sideways, chocolate in one hand, wine in the other, body thoroughly used up, totally worn out and screaming "WOO HOO what a ride!"